Journal of Plastic, Reconstructive & Aesthetic Surgery (2020) 73, 2086–2102

Correspondence and Communications

Undergraduate plastic
surgery in the United
Kingdom: The students’
perspective

Dear Sir,

Plastic Surgery is consistently ranked as one of the most

competitive specialties for higher surgical training in the
United Kingdom (UK).1 Despite the benefits of early under-
graduate exposure, Plastic Surgery still occupies a negligible
portion of curricula at many medical schools, with rates of
formal Plastic Surgery teaching in UK medical schools falling
from 78% in the 1980s to 13% in 2008.2 There is a danger that
potentially excellent candidates will be deterred from ap-
plying for training positions, thus we sought to investigate a
cohort of UK medical students with an established interest
in Plastic Surgery with regard to the factors that influence
their interest in the specialty.
A cross-sectional study design was used with question-
naires distributed to medical students attending the BAPRAS
Undergraduate Day in London and Glasgow University Plas-
tics Undergraduate National Conference in 2019. The ques-
tionnaire (available online as supplementary material) cov-
ered the following domains:
1. Demographic information
2. Attracting and deterring factors for a career in Plastic
Surgery
3. Knowledge regarding application requirements for Plas-
tic Surgery Training
4. Undergraduate exposure to Plastic Surgery
5. Suggestions to improve undergraduate experience in
Plastic Surgery
Figure 1 (a) Ten most common attracting factors. (b) Ten most
Out of 145 conference attendees, 82 (57%) participated common deterring factors.
in the study. The median medical school year of study across
the cohort was year four. A total of 22 UK medical schools
were represented between both conference days. tional selection process (41%), work-life balance (15%) and
The most common factors attracting students to a career length of training (12%). Of students surveyed, 35% stated
in Plastic Surgery (Figure 1a) were variety (25%), surgical in- that they were aware of the requirements of the Plastic
tricacy (15%) and immediate effect on patient quality of life Surgery national selection process. This demonstrates a dis-
(12%). The most common factors deterring students from a connection between perceptions around fierce competition
Plastic Surgery career (Figure 1b) were a competitive na- for entry into Plastic Surgery training and the reality of
often not knowing what the application actually involves.
Content previously presented at: 3rd BFIRST/BSSH Overseas Day This highlights an opportunity for interventions to educate
Symposium, Edinburgh, 13th September 2019; ASiT 2020, Birming- medical students about higher surgical training applications
ham, 7–8th March 2020. so that they can then prepare more effectively for them
Correspondence and Communications
Figure 2 Five most common suggestions for improvements to undergraduate plastic surgery training.
in advance, which may reduce the chance that excellent
candidates are unnecessarily dissuaded from selecting the
career.
A small majority (53%) reported receiving undergraduate
teaching in Plastic Surgery, either in the form of lectures
or integrated clinical placements. Almost as many (45%)
had experienced Plastic Surgery outside of university, ei-
ther through setting up external experiences with Plastic
Surgeons at their university, abroad via a medical elective
or at surgical course or educational evening set up by sur-
gical society. These results demonstrate that many medical
students will not experience Plastic Surgery during their un-
dergraduate education and so their perceptions of the spe-
cialty will be likely be influenced from external sources,
such as television and other media.3 These perceptions are
often negative, propagating the fallacy that Plastic Surgery
is mostly concerned with cosmetic surgery and private prac-
tice, which were deterring factors for the students we sur-
veyed. If students do not meet Plastic Surgeons, they will
miss out on positive role models, who play an integral role in
mentoring and developing successful careers.4 , 3 This is es-
pecially important for female medical students, as positive
female role models are one of the most influential factors
for female students interested in surgery.4
When asked what students believed would improve
their undergraduate Plastic Surgery experience, the most
common response was for more clinical exposure to the
speciality in the undergraduate setting and formalised
teaching (Figure 2). Ideally we would advocate the imple-
mentation of Plastic Surgery placements into undergraduate
curricula of UK medical schools but appreciate the diffi-
culties associated with this and as an alternative, short
courses and workshops can provide time and cost-efficient
2087
methods of improving exposure to the specialty.5 Currently,
university surgical societies often fill this role, but this has
ramifications in terms of equity of access and would be
more appropriately provided by educational or professional
institutions.
In summary, UK Medical students are interested in ca-
reers in Plastic Surgery and have a good understanding of
what the career entails. Whilst the main deterring factor
stated was the competition to obtain a training position,
the majority of students were unable to correctly state the
requirements for this competitive process. The reason for
this is likely multifactorial, linked to a lack of clinical ex-
posure and formal teaching in the undergraduate medical
curriculum. Universities should collaborate with local Plas-
tic Surgery departments and national professional bodies to
meet the needs of medical students for Plastic Surgery ex-
posure through mentorship, workshops, taster days and clin-
ical placements.
Declaration of Competing Interest
The authors declare no conflict of interest. No funding was
received for this study.
Supplementary materials
Supplementary material associated with this article can be
found, in the online version, at doi:10.1016/j.bjps.2020.08.
086.
2088
References
1. Health Education England. Specialty recruitment competi-
tion ratios 2019. https://specialtytraining.hee.nhs.uk/Portals/
1/Competition%20Ratios%202019_1.pdf. [Accessibility verified
May 6, 2020]
2. Wade RG, Clarke EL, Leinster S, Figus A. Plastic surgery in the
undergraduate curriculum: a nationwide survey of students, se-
nior lecturers and consultant plastic surgeons in the UK. J Plast
Reconstruct Aesthet Surg 2013;66:878–80.
3. Farid M, Vaughan R, Thomas S. Plastic surgery inclusion
in the undergraduate medical curriculum: perception, chal-
lenges, and career choice—a comparative study. Plast Surg Int
2017;2017:9458741.
4. Ramanadham SR, Rohrich RJ. Mentorship: a pathway to succeed
in plastic surgery. Plast Reconstr Surg 2019;143:353–5.
5. Khatib M, Soukup B, Boughton O, Amin K, Davis CR, Evans DM.
Plastic surgery undergraduate training: how a single local event
can inspire and educate medical students. Ann Plast Surg
2015;75:208–12.
Terouz Pasha
Faculty of Life Sciences and Medicine, King’s College
London, 18-20 Newcomen Street, London SE1 1UL,
England, United Kingdom
Eleanor S. Lumley
Glasgow Royal Infirmary, Glasgow, Scotland, United
Kingdom
Louis Dwyer-Hemmings
Institute of Medical and Biomedical Education, St
George’s University (University of London), London,
England, United Kingdom
Matthew Fell
North Bristol NHS Trust, England, United Kingdom
E-mail address: terouz@gmail.com (T. Pasha)
© 2020 British Association of Plastic, Reconstructive and Aesthetic
Surgeons. Published by Elsevier Ltd. All rights reserved.
https://doi.org/10.1016/j.bjps.2020.08.086
Percutaneous needle
fasciotomy for Dupuytren’s
disease: A one-stop
approach incidentally suited
to the era of COVID-19R
Dear Sir,
The era of COVID-19 has and continues to present a
unique challenge to the provision of healthcare across the
R Institution where work should be attributed: Department of
Plastic and Reconstructive Surgery, Royal Devon and Exeter NHS
Foundation Trust, Exeter, UK
Correspondence and Communications
National Health Service. The redeployment of many theatre
personnel and anaesthetists to areas of high Covid-burden
has seen surgical practice drastically condensed. Here
we describe an example whereby percutaneous needle
fasciotomy (PNF), delivered as the treatment of choice for
Dupuytren’s, facilitated continued service provision at an
unaffected standard for patients presenting to our unit.
Upon the announcement of ‘lockdown’ and with the
redeployment of many anaesthetists and theatre personnel
to ‘Covid-red areas’, plastic surgery staff at our unit were
reorganised into three main teams providing service in
cancer, urgent electives and trauma. All elective lists were
subsequently deferred, effective on March 17th in line
with national guidelines. The majority of theatres across
the Trust were stripped of ventilators and other equip-
ment. Such restrictions to service, though undoubtedly
needed, have compounded excess morbidity and mortality
as an indirect consequence of the pandemic, estimates of
which are difficult to evaluate and may inevitably have an
enduring impact.
As the expected load of Covid patients was mercifully
not seen in our region, limited resourcing for outpa-
tient procedures was maintained such that less resource
intensive procedures including PNF for Dupuytren’s con-
tracture could be carried out in a one-stop approach. In
this method, patients are COVID-tested and those patients
proven COVID-negative are offered to attend for PNF, which
is carried out in procedure rooms by a surgeon and a single
assistant, without the requirement for an anaesthetist or
ventilator. Following fasciotomy, patients directly see hand
physiotherapy for fitting of a thermoplastic splint which
they are able to remove for short periods as required.
Patients are not required to have nurse follow-up at seven
days post-operatively (as per usual protocol) but are given
details of the plastic surgery ward to contact if required,
limiting avoidable exposure to both staff and patients.
Additionally, patients are followed up via telemedicine at
three months to evaluate the outcome of the procedure.
Though this precludes physical examination, patients are
typically asked questions such as ‘How are you finding the
use of your hand today?’, ‘How straight is your finger now?’,
‘Is the sensation to your finger as before the procedure?’
and ‘Would you have the procedure again if necessary?’ in
order to assess outcomes and patient satisfaction.
Though an established technique with documented
safety in several large series studies including that by
Therkelsen et al.,1 there is a relative paucity in the liter-
ature regarding the provision of ‘office-based’ PNF which
has also shown to be effective without compromise to
patient safety.2 The increased uptake of such practices
may be vital in conserving theatre space, a resource which
is likely to remain limited for the foreseeable future,
enabling greater capacity for more demanding procedures
and cases with greater need and/or complexity. As the
demand for elective hand surgery continues to rise3 against
the expected backdrop of economic recession and rationed
healthcare, it may be essential to increase the provision of
more sustainable and cost-effective approaches to treating
surgical hand disease. In the era of COVID-19, when anaes-
thetists, ventilators and other resources are a scarcity, we
found that PNF facilitated a one-stop treatment approach
to treatment of Dupuytren’s disease and as such is ideally
Correspondence and Communications
suited to continue service provision in this time of extreme
resource limitation.
Declaration of Competing Interest
The authors would like to confirm that there are no conflicts
of interest.
Funding
No funding has been obtained for this work.
References
1. Therkelsen LH, Skov ST, Laursen M, Lange J. Percutaneous nee-
dle fasciotomy in Dupuytren contracture: a register-based, ob-
servational cohort study on complications in 3,331 treated fin-
gers in 2,257 patients. Acta Orthop 2020;91(3):326–30.
2. Chambers J, Pate T, Calandruccio J. Office-based percutaneous
fasciotomy for dupuytren contracture. Orthop Clin North Am
2020;51(3):369–72.
3. Bebbington E, Furniss D. Linear regression analysis of hospital
episode statistics predicts a large increase in demand for elec-
tive hand surgery in England. J Plast Reconstr Aesthet Surg
2015;68(2):243–51.
Manal I. Patel
University of Cambridge School of Clinical Medicine,
Cambridge, CB2 0SP, UK
Irshad A. Patel
Department of Plastic and Reconstructive Surgery, Royal
Devon and Exeter NHS Foundation Trust, Exeter, EX2 5DW,
UK
E-mail address: mp778@cam.ac.uk (M.I. Patel)
© 2020 British Association of Plastic, Reconstructive and Aesthetic
Surgeons. Published by Elsevier Ltd. All rights reserved.
https://doi.org/10.1016/j.bjps.2020.08.037
Ultrasound guided
liposuction for
superficialization of difficult
to access arteriovenous
fistulas
Dear Sir,
Arteriovenous fistulas (AVF) remains the preferred
method of vascular access for hemodialysis due to fa-
vorable patency rates, low infection rates, and fewer
2089
complications.1 In order for an AVF to be used, it requires
adequate maturation and should be easily cannulated. In
addition to affecting maturation, excess adipose tissue
overlying the vessels in obese patients often makes the AVF
too deep to cannulate for hemodialysis and can necessitate
more extensive procedures in order to access the vessels.
The recommended vein depth for reliable cannulation is
<6 mm to allow repeated safe cannulation.2 In order to do
this, vein elevation, surgical excision of fatty tissue, and
tunneled vein transposition have been used to superficialize
vessels. However, patients with a high BMI require addition-
ally large incisions that can develop surgical site complica-
tions such as prolonged wound healing duration.3
Liposuction to superficialize AVFs is an emerging proce-
dure with limited reports of its use. Though minimally in-
vasive, the procedure is somewhat subjective, and it may
be difficult to assess when “enough” has been done. Ultra-
sound guidance can help objectively evaluate the effective-
ness of the procedure, in addition to ensuring the safety of
the procedure by maintaining visualization of the AVF at all
times. We describe our technique and experiences with ul-
trasound guided liposuction (UGL) as a promising method for
salvaging deep AVFs for dialysis.
Four patients were included in this study, three of which
had a brachiocephalic fistula. All patients had adequate
maturation with flow rates >600 mL/min. The mean depth
of AVF access was determined pre- and postoperatively in
each patient via ultrasound (Table 1, Figure 1). Technical
success was defined as a continuous thrill being palpable
along the entire length of the vessel needle access point
(NAP), and ultimately, the vessel successfully cannulated,
and hemodialysis performed. There were no intraopera-
tive or postoperative complications. Technical success was
achieved in all cases.
In contrast to large incisions and manipulation of ves-
sels with traditional superficialization procedures, liposuc-
tion allows for removal of excess fat without need for ad-
ditional anastomosis through a single small incision. Prior
groups have used a protective shield overlying the AVF to
guard the vessel from damage, and ultrasonic-powered li-
posuction to liquefy subcutaneous fat at the canula’s distal
tip. However, ultrasonic liposuction is known to be associ-
ated with burns and seromas from the thermal and mechan-
icals disruption of surrounding adipocytes. The use of con-
tinuous ultrasound guidance removes the need for a device
to guard the AVF while avoiding the risk of damaging neigh-
boring structures along the NAP with direct visualization.
Furthermore, injection of tumescent solution prior to lipo-
suction reduces bleeding during the procedure while enlarg-
ing the deep adipose layer to be aspirated, thereby preserv-
ing more superficial layers and avoiding the thermal effects
of ultrasonic liposuction.
Although the patients in our study experienced no com-
plications, caution should be exercised for liposuction, and
users must be wary of accidental injury to the fistula with
the canula. A large cavity left behind after deep liposuc-
tion may involve a higher risk of complications including
scarring, fat emboli, hematoma, or soft tissue deformity re-
quiring removal or revision as the maximal depth at which
liposuction should be performed to superficialize a venous
outflow track has yet to be determined. Ultrasound guid-
2090 Correspondence and Communications

Table 1 Patient information.

# Gender Age BMI AVF Prior Preop. Mean Postop. Mean Lipoaspirate Time of AVF Comorbidities
(kg/m2 ) AVF vein depth vein depth Volume (mL) creation to
(mm) (mm) Superficialization
1 F 61 34 Brachiocephalic Y 16 6 110 66 DM2
2 F 68 30.2 Brachiocephalic Y 11 4 80 39 DM2, HTN
3 F 74 27.3 Brachiocephalic Y 14 6 60 16 DM2, HTN,
PAD
∗ Abbreviations: BMI: Body mass index; AVF: arteriovenous fistula; DM2: diabetes mellitus type 2; HTN: hypertension; PAD: peripheral
arterial disease.

Figure 1 Ultrasound examination of the arteriovenous fistula before (A) and after (B) liposuction.

ance, however, can help mitigate some of these potential
complications. We find ultrasound guided liposuction to be
a safe and effective minimally invasive method for superfi-
cialization of AVFs through a single small incision with short
operative times.
Once a palpable thrill was felt through the skin and an even
depth was achieved along all points of the NAP, the area was
irrigated and steri-strips were applied after closure with a
3–0 vicryl followed by a 4–0 monocryl subcuticular stitch.

Funding

Technique None.

A regional block was performed in the target arm for all

patients. Patients laid in a supine position with the arm ab-
ducted at a 90-degree angle. Under B-mode ultrasound guid-
ance, the AVF and venous outflow tract was mapped and
an incision site was selected. A 1 cm incision was created.
Under ultrasound guidance 50–100 mL of tumescent solution
(1 L normal saline, 30 mL of 1% lidocaine, and 1:1000 dilu-
tion of 1 ampule epinephrine) was infiltrated on both sides
of the venous outflow tract followed by a 10-minute wait for
the tumescent solution of take effect.
Using a 3 mm spatula cannula, liposuction was performed
over the top of the fistula with the bevel directed away from
the vessel, and the cannula angled toward the skin to avoid
damage to vasculature. Liposuction was carried out directly
lateral to and overlying the AVF in a radial pattern. This al-
lowed for adequate visualization of the AVF path as well as
width once the thinned skin has scarred down along the fis-
tula’s anterior surface upon healing. Ultrasound was used to
verify the depth of the venous outflow tract and position of
the cannula every 10 mL of lipoaspirate that was removed.
Sources of financial support
None declared.
Declaration of Competing Interest
None declared.
References
1. Smith GE, Gohil R, Chetter IC. Factors affecting the pa-
tency of arteriovenous fistulas for dialysis access. J Vasc Surg
2012;55(3):849–55. doi:10.1016/j.jvs.2011.07.095.
2. Santoro D, Benedetto F, Barillà D, et al. Vascular access for
hemodialysis: current perspectives. Published online 2014:281–
294.
3. Pierpont YN, Dinh TP, Salas RE, et al. Obesity and surgical wound
healing : a current review. 2014;2014:21–25. doi:10.1155/2014/
638936.
Correspondence and Communications
Alan Nguyen
Oakland University William Beaumont School of Medicine,
Rochester, MI, United States.
Ashraf A. Patel
College of Medicine, SUNY Upstate Medical University,
Syracuse, NY, United States
Venita Chandra
Division of Vascular Surgery, Stanford University Medical
Center, Palo Alto, CA, United States
Rahim S. Nazerali
Division of Plastic and Reconstructive Surgery, Stanford
University Medical Center, 770 Welch Road, Suite 400, Palo
Alto, CA 94304, United States
E-mail address: rahimn@stanford.edu (R.S. Nazerali)
© 2020 British Association of Plastic, Reconstructive and Aesthetic
Surgeons. Published by Elsevier Ltd. All rights reserved.
https://doi.org/10.1016/j.bjps.2020.08.035
Roadmap for the use of
FACE-Q skin cancer module
in multidisciplinary practice,
Dear Sir,
Data from patient-reported outcome measures (PROMs)
have been adopted in outcome-based research.1 There is
an increasing interest to integrate PROMs data into routine
practice to improve care management pathways.2 The au-
thors report the features of a roadmap for the use of FACE-
Q Skin Cancer Module, a new skin cancer-specific PROM
for facial lesions,3 in multidisciplinary practice. Targeting
the maximization of the patient-clinician encounter and
standardization of data collection led to this roadmap’s
(Figure 1) gradual construction (using a problem-solving
model with constant monitoring and adjustment). This was
based on an accumulated experience of the authors during
the process of validation of the FACE-Q Skin Cancer tool into
Brazilian-Portuguese language as well as the use of the vali-
dated PROM in a multidisciplinary practice model managing
patients with private health insurance.
For a proper understanding of patients’ perceptions
throughout the cycle of surgical care while monitoring pa-
tients’ progress and identification of problems, the selected
scales and checklists were routinely applied at predefined
time points (preoperative and 1, 6, 12, and 24 months post-
surgery), and also administrated for particular symptoms-
Financial disclosure: None.
Conflict of Interest: There are no conflicts of interest to disclose.
2091
and request-driven time points (e.g., request for scar re-
vision 3 months after surgery) on a case-by-case approach.
The adoption of tablets (during the waiting time for office
visits) or personal computers (at home) assisted this process
for the use of FACE-Q data during consultations. A FACE-Q
administrator (a trained non-clinician member of staff) ac-
celerated this workflow by contacting patients, preparing
the dataset for consultation, and storing the data. During
the postoperative period, the individual data of each pa-
tient allowed clinicians to assess the scores’ fluctuations.
Clinicians working with a multidisciplinary team-based ap-
proach in the same building facilitated the intrateam inter-
action with prompt FACE-Q-driven actions. Not only were
the overall Rasch score-based interventions implemented
(e.g., pscyhological support to deal with cancer-related ap-
prehension as measured by the Cancer Worry scale) but each
item was also addressed during consultation. For example,
during the evaluation of the Sun Protection Behavior scale,
the item “how often have you worn sunscreen when you
were outside?” was adopted to reinforce the need for reg-
ular use of sunscreen, contributing to patient instructions
(just-in-time education model) and engagement with care.
As FACE-Q was adopted during clinical evaluations, we have
perceived that the patients have properly and timely an-
swered the scales. The PROM also improved their ability to
describe their concerns and feelings.
This roadmap should not be interpreted as unique or ab-
solute as it can be revised and adapted to other health care
settings, organizational system, and to the composition of
multidisciplinary teams, with distinct challenges for imple-
mentation. Despite the existence of literature-derived sup-
port for the described strategies,4 , 5 future robust analyses
could judiciously assess the impact of this roadmap on pa-
tients and clinicians’ time burden, patient-clinician com-
munication, PROM-driven changes in interventions, patient
satisfaction with care, and whether outcomes are improved
as a result. Future investigations should also generate cut-
points and define normative data which could enhance rou-
tine use and interpretations of individual FACE-Q data to-
ward the delivery of truly personalized patient care.5
References
1. Rivera SC, Kyte DG, Aiyegbusi OL, Slade AL, McMullan C,
Calvert MJ. The impact of patient-reported outcome (PRO) data
from clinical trials: a systematic review and critical analysis.
Health Qual Life Outcomes 2019;17:156.
2. Dobbs TD, Hughes S, Mowbray N, Hutchings HA, Whitaker IS.
How to decide which patient-reported outcome measure to use?
A practical guide for plastic surgeons. J Plast Reconstr Aesthet
Surg 2018;71:957–66.
3. Lee EH, Klassen AF, Cano SJ, Nehal KS, Pusic AL. FACE-Q skin
cancer module for measuring patient-reported outcomes fol-
lowing facial skin cancer surgery. Br J Dermatol 2018;179:88–
94.
4. Basch E, Barbera L, Kerrigan CL, Velikova G. Implementation of
patient-reported outcomes in routine medical care. Am Soc Clin
Oncol Educ Book 2018;38:122–34.
5. Brundage MD, Wu AW, Rivera YM, Snyder C. Promoting ef-
fective use of patient-reported outcomes in clinical practice:
themes from a "methods toolkit" paper series. J Clin Epidemiol
2020;122:153–9.
2092 Correspondence and Communications

Figure 1 The FACE-Q-based roadmap. As the FACE-Q scales (appearance satisfaction, quality of life, and patient experience) and
checklists (sun protection and adverse effects) can be used independently in any given combination or order with individualization
of scores, clinicians have adopted only those that were relevant to a specific contexts throughout the continuum of care, that is,
diagnosis, surgical treatment, recovery, and follow up processes. The FACE-Q data (item level responses and Rasch scores) acted
as a trigger element for cascades of actions and interventions in a shared-decision making approach. The patients’ reports were
inserted within the clinical flow, for example, patients reported their symptoms (Adverse Effects checklist) just before the clinical
appointment (at home or waiting room) and received immediate symptom-tailored recommendations and treatment. The constant
interaction between clinicians while crosschecking with the FACE-Q administrator avoided patient burden when it came to re-
answering a scale that they had recently completed. For example, the dermatologist and plastic surgeon’s interest in the Appraisal
of Scars scale to identify a potential poor patient-perceived result and then plan the best-suitable therapeutic intervention, did not
have to be re-answered.
Rafael Denadai∗ country. Medical and surgical specialties live as they are in
Institute of Plastic and Craniofacial Surgery, SOBRAPAR a “parallel world”, which exists alongside the Intensive Care
Hospital, Sao Paulo, Brazil Units, the Departments of Infectious Disease, Pneumology,
Private practice, Dermatology & Plastic Surgery clinic, Hygiene and all the buildings which have been converted in
Sao Paulo, Brazil COVID buildings in order to assist infected or suspected of
being infected people. The most difficult prediction is the
Karin Milleni Araujo maximum number of infected patients that will be reached
Private practice, Dermatology & Plastic Surgery clinic, in Italy and, most importantly, the maximum number of pa-
Sao Paulo, Brazil tients who will require intensive care unit admission.1
The social significance of the almost heroic task of those
∗
Corresponding author. who fight the virus, fighting against time, and the treatment
E-mail address: denadai.rafael@hotmail.com (R. Denadai) strategies to be invented persuade that this is the only med-
ical battle to be won. We certainly cannot blame it: the
© 2020 British Association of Plastic, Reconstructive and Aesthetic coronavirus is the game of life but also the game of medical
Surgeons. Published by Elsevier Ltd. All rights reserved. science.
But who is on the other side?
https://doi.org/10.1016/j.bjps.2020.08.083 If the coronavirus dictates the planetary health agenda,
certainly the other disciplines, alas, do not live between re-
ality and memory. The idea of a certain snobbery towards
some surgical branches such as plastic surgery does not re-
ally coincide with the sudden increase in specific surgical
Plastic surgery in the time of cases. Indeed, it is curious to observe how the urgent provi-
sions concerning the contrast and containment of the spread
Coronavirus in Italy. Can we of the COVID-19 virus issued by the Italian Government with
really say “Thanks God we the DD.PP.CC.MM. of 08.03.2020 and 09.03.2020 may have
influenced this trend.
are plastic surgeons?” Something has changed since people have been forced at
home, wondering what to do.
Dear Sir, We reviewed the data of all the patients admitted to our
Plastic Surgery Unit, which is located in a COVID hospital,
We may all imagine how things go when a huge tragedy from our institution digital databases from the 1st to the
like that of COVID-19 hits on the health care system of a 31st of March 2020 and we compared those data with the
Correspondence and Communications
Figure 1. Comparison of the total admissions in Plastic Surgery Unit between March 2020 and March 2015-2019 (average value).
Figure 2. Comparison of admissions for home hand accidents between March 2020 and March 2015-2019 (average value).
ones of the previous 5 years. In accordance with the Cir-
culars of the Ministry of Health, the ordinary hospitalization
and outpatient activities have all been remodulated in order
to meet the potential increase in hospitalization needs and
to limit patient flows within the care facilities. Only urgent
or emergency surgery or not postponable oncologic surgery
have been guaranteed. As a matter of fact, the number of
total admissions in our Unit demonstrated a reduction rate
of 85% (Figure 1). On the other hand, the results of the sta-
tistical analysis for the month under review has shown that
hand trauma related to home accidents have raised of 15.8%
on average compared to the same period of the previous five
years. This figure has been essentially the result of clumsy
experiments with tutorials for carpentry works of all kinds,
bricolage and gardening, with the milder weather as an ex-
cellent ally (Figure 2).
The anxiety and the fear of contagion have led many to
do-it-yourself for the sanitization of environments and the
hygiene of hands and clothes. Quite for this reason, ten pa-
tients were admitted to our Burn Center this month alone.
The 67% of the patients were treated for burns caused by
denatured alcohol, while in the 33% of the cases, the injury
2093
was caused by the improper use of corrosive substances,
awkwardly used for the artisanal realization of disinfec-
tants. The total number is 22% higher than the five years
before.
Not even the prison system has remained foreign to the
previous observations, with reference to patients who had
needed recovery and treatment in a plastic surgery depart-
ment. Riots in Italian prisons hit the headlines after the Ital-
ian Government decision to discontinue visiting from rela-
tives. Maxillofacial trauma admitted to the selected Depart-
ments raised from the last 5 years of 35%.
The Plastic Surgery Community continues to work
and to fight the same universal battle with the same
sense of responsibility. Responsibility to be part of the
cure and not part of the disease.2 For instance, dedi-
cated plastic surgery teams comprising attending physi-
cians and residents have been established in our Cen-
ter. They do not come into contact with each other and
alternate on a weekly basis. We should be role mod-
els for good hand hygiene and enforce strict compliance
to minimize disease spread and not add to the general
hysteria.3
2094
Declaration of Competing Interest
None.
Funding
None.
References
1. Remuzzi A, Remuzzi G. COVID-19 and Italy: what next? Lancet
2020. doi:10.1016/S0140- 6736(20)30627- 9.
2. Rose C. Am i part of the cure or am i part of the disease? Keeping
coronavirus out when a doctor comes home. N Engl J Med 2020
null. doi:10.1056/NEJMp2004768.
3. Chang Liang Z, Wang W, Murphy D, Po Hui JH. Novel coronavirus
and orthopaedic surgery: early experiences from Singapore. J
Bone Jt Surg Am 2020. doi:10.2106/JBJS.20.00236.
Rossella Elia∗ , Giuseppe Giudice, Michele Maruccia
Unit of Plastic and Reconstructive Surgery, Department of
Emergency and Organ Transplantation, University of Bari,
11, Piazza Giulio Cesare, Bari 70124, Italy
∗
Corresponding author.
E-mail addresses: rossellaelia4@gmail.com,
rossella.elia@hotmail.it (R. Elia)
© 2020 British Association of Plastic, Reconstructive and Aesthetic
Surgeons. Published by Elsevier Ltd. All rights reserved.
https://doi.org/10.1016/j.bjps.2020.08.081
How defined an abdomen
should be: Survey-based
study with young women
Dear Sir,
Cultural beliefs, social media, perception of other peo-
ple, and several other issues can directly influence the pa-
tient’s self-image1 ; hence, the ideal abdomen is not the
same for every patient. To better understand these vari-
ables a prospective survey was conducted of volunteers of a
Brazilian hospital recruited randomly through an email sur-
vey from January 2020 to April 2020. The Hospital de Clíni-
cas de Porto Alegre’s institutional review board approval
was granted.
The inclusion criteria were being a female medical resi-
dent; there were no exclusion criteria. Based on percent-
ages found in the ongoing literature, the sample size of
80 participants was calculated based on the expected dif-
ference among groups, with alpha error 0.05 and power of
80%.2
Correspondence and Communications
Data was collected sending an email to the academic
mailbox of 150 female residents of a particular University-
related Hospital. After the first email, 3 reminders were
sent. In the email, firstly was described as a short abstract,
the objective, and the confidentiality statement of the sur-
vey so that volunteers understand the relevance of it. Then
it was asked the age of the participant, how many times
does she practice physical activity during the week, and if
she was totally, partially or not satisfied with her current
abdomen muscle definition. Finally, using the classification
proposed by Viaro (supplementary figure 1)3 with the writ-
ten and figure description added to an actual photograph ex-
ample, it was asked which grade of the classification would
best fit in her goal of abdominal etching.
The comparison of the variable age was assessed through
the ANOVA test. All other variables were evaluated through
the exact fisher test. For all comparisons, the significance
level of 0.05 was considered.
A total of 81 female participants were interested in the
survey. The response rate was 54%. The age range of the vol-
unteers was between the ages of 24 and 40 years, being an
average of 27.6 years. Furthermore, 88% of the participants
were aged 25–30 years. The age did not directly influence
the abdominal etching grade goal.
As proposed by Gould, participants who exercise (any
sort of physical activity was considered) at least twice a
week were considered the exercise cohort; and, who did
not, the sedentary cohort.2 It was found that 65% (53) of all
study participants claimed to exercise at least twice a week
("exercise cohort"), whereas 25% (28) of study participants
exercised one or no times per week ("sedentary cohort").
(Supplementary figure 2) The cohort of individuals that ex-
ercised multiple times per week was more likely to desire a
higher grade of abdominal muscle definition goal with a sta-
tistically significant difference (Figure 1) (p < 0.05). There
was no statistically significant correlation between satisfac-
tion with the current abdomen and one specific ideal of ab-
dominal muscle definition grade.
There is a current tendency to the High Definition Lipo-
suction (HDL). As described by Hoyos, because HDL is de-
signed to be a sculpting procedure rather than a debulking
technique, appropriate patients should have good muscle
tone without an excessive amount of fat or skin laxity (Body
Mass Index < 30 cm/m2 ).4 Young patients with good under-
standing are natural candidates for high definition liposuc-
tion; then, young residents would be a representative group
of this population.
Hoyos described HDL as a precision technique, involving a
3-dimensional multilayer concept of body contouring, stat-
ing that it is "all or nothing lipoplasty" once the whole body
musculature must match in order to allow natural and op-
timal results.4 Our findings agree with Hoyos statement. On
our survey it can be observed once the more physically ac-
tive (better body musculature strength) – the volunteer was
(better body musculature strength), the higher her abdom-
inal etching ideals were. However, even among those with
the greatest physical activity a minority desires the appear-
ance of multiple packs.
Although this study is restricted to a specific group of
patients, and the response rate was 54% even though 3 re-
minders were sent to the participants who did not answer
the survey; it serves as a guide to a discussion of the pa-
Correspondence and Communications
Figure 1 (A) The proportion of individuals in the sedentary cohort that consider each grade of abdominal etching ideal (B) The
proportion of individuals in the exercise cohort that consider each grade of abdominal etching ideal.
tient’s wishes regarding their goals and frustrations con-
cerning their fitness objectives with a surgical procedure.
We also highlight that the procedure is not risk-free, and
that must be taken into consideration.5
In conclusion, our study did have limitations inherent to
our methodology. Although it is fair to conclude from these
data that physical activity is directly related to the abdom-
inal muscle definition grade pursued. It is also plausible of
concluding that appearance of the patients’ "4, 6, or even
8 pack" muscle is not an aesthetic ideal for most patient.
Importantly, the level of etching may differ, and patients
may have divergent desires. We believe this discussion must
be included in every preoperative body contour consulta-
tion; also, evaluating each patient with a careful and real-
istic sense may be the way to achieve patient and surgeon’s
satisfaction. This conclusion should be further evaluated
2095
in future studies including other particular variables and
groups.
Disclosures
All authors have seen and approved the manuscript.
The current "Guide for Authors" has been read
The authors declare that they have no conflict of inter-
ests.
The authors declare that they have no funding.
The research followed the Helsinki principles.
If accepted, the paper will not be published elsewhere in
the same or similar form, in English or in any other language,
without written consent of the copyright holder
The authors declare that they have no conflict of inter-
ests or funding.
2096
Supplementary materials
Supplementary material associated with this article can be
found, in the online version, at doi:10.1016/j.bjps.2020.08.
082.
References
1. von Soest T, Kvalem I, Roald H, Skolleborg K. The effects of
cosmetic surgery on body image, self-esteem, and psychological
problems. J Plast Reconstr Aesthet Surg 2009;62(10):1238–44.
doi:10.1016/j.bjps.2007.12.093.
2. Gould D, Shauly O, Qureshi A, Stevens W. Defining “Ideal Abs”
through a crowdsourcing-based assessment. Aesthet Surg J
2020;40(4):NP167–73. doi:10.1093/asj/sjz344.
3. VIARO M. Abdominal etching. Revista Brasileira de Cirurgia Plás-
tica (RBCP). Braz J Plast Sug 2019;34(3):336–43. doi:10.5935/
2177-1235.2019rbcp0205.
4. HOYOS A, MILLARD J. VASER-assisted high-definition liposculp-
ture. Aesthet Surg J 2007;27(6):594–604. doi:10.1016/j.asj.
2007.08.007.
5. Zanin E, Portinho C, Stensmann I, Maximiliano J, Oliveira A,
Collares M. Severe and massive necrosis following high defini-
tion power-assisted liposuction: a case report. Eur J Plast Surg
2020. doi:10.1007/s00238- 020- 01678- 0.
Antônio Carlos Pinto Oliveira
Eduardo Madalosso Zanin
João Maximiliano
Daniele Walter Duarte
Isabel Cristina Wiener Stensmann
Ciro Paz Portinho
Marcus Vinicius Martins Collares
Division of Plastic Surgery, Hospital de Clínicas de Porto
Alegre, Ramiro Barcelos st., 2350, ZIP 90035-007 Porto
Alegre, RS, Brazil
E-mail address: eduardo.zanin@gmail.com (E.M. Zanin)
© 2020 British Association of Plastic, Reconstructive and Aesthetic
Surgeons. Published by Elsevier Ltd. All rights reserved.
https://doi.org/10.1016/j.bjps.2020.08.082
Letter comments on: “Use
of a virtual 3D anterolateral
thigh model in medical
education: Augmentation
and not replacement of
traditional teaching?”
Dear Sir,
It was our pleasure to read the article by Lo et al.,1 who
applied a virtual three-dimensional (3D) anterolateral thigh
model in medical education. Indeed, the study showed that
Correspondence and Communications
this model could be proved useful for anatomy teaching
and able to complement traditional methods. However, the
authors stated that “despite the appetite for virtual and
augmented reality models, empirical evidence support-
ing current technologies is limited”, doubting that those
technologies could significantly contribute to acquisition
of anatomical knowledge. We would like to note that the
literature has provided strong evidence to support 3D
digital visualization technologies, including virtual reality
(VR) and augmented reality (AR), not only in anatomical
education, but also in several fields of plastic surgery.
The study by Lo et al.1 evaluated students’ perceptions
after the educational intervention via the virtual model, as
well as via traditional methods, including two-dimensional
(2D) images and lectures. However, knowledge acquired by
students via the virtual model, lectures and 2D images was
not assessed, as it was also noted in the commentary by
Chu and Fan.2 Our respectful disagreement with the opinion
expressed by Lo et al. 1 is not based on studies which just
evaluated students’ perceptions, but on reviews of the lit-
erature. These reviews have included comparative studies,
which have illustrated the benefits of 3D computer-based vi-
sualization, VR and AR in terms of acquisition of anatomical
knowledge and aid in plastic surgery practice. On the other
hand, to the best of our knowledge, there is no published
review article to support the superiority of traditional 2D
anatomy teaching methods to 3D ones.
Yammine and Violato3 published a meta-analysis of stud-
ies which compared 3D visualization technologies, including
VR, with other anatomy teaching methods. It was found that
3D visualization led to significantly higher spatial anatomy
knowledge acquisition compared to other methods. The re-
sults of the meta-analysis had high internal validity for bet-
ter outcomes of 3D technologies in comparison with other
anatomy education modalities.
Triepels et al.4 performed a systematic review of stud-
ies which compared 3D digital models (including VR and AR)
with traditional anatomy teaching tools. It was concluded
that 3D digital visualization led, in general, to significant
improvement of anatomical knowledge in comparison with
traditional 2D modalities.
Since the aforementioned review articles demonstrated
the high potential of 3D visualization methods to enhance
anatomy knowledge, it could be concluded that those tech-
nologies provide students with adequate illustration of 3D
anatomy of structures of the human body. Thus, it could be
hypothesized that this illustration could also be beneficial
for surgeons. Indeed, especially concerning plastic surgery,
the systematic review by Sayadi et al.5 showed that VR
and AR have remarkable ability to contribute to preopera-
tive planning, surgical training and intraoperative decision-
making and to reduce operative errors.
The article by Lo et al.1 proposed that VR could aug-
ment and not replace traditional anatomy teaching, as it
was indicated by students’ perceptions. We consider that
decisions regarding augmentation or replacement of tradi-
tional anatomy teaching tools should not be based on stu-
dents’ perceptions but on data concerning illustration of
spatial anatomy and acquisition of anatomical knowledge.
Chu and Fan,2 in their commentary, stated that there is
need for studies to compare students’ performance with
and without 3D virtual models. In contrast, we believe that
Correspondence and Communications
the aforementioned review articles have demonstrated that
3D visualization technologies could essentially contribute to
enhancement of anatomy knowledge, adequate illustration
of 3D anatomy and improvement in plastic surgery planning,
navigation and training.
Given that plastic surgery has a 3D nature of educa-
tion and practice,1 we consider that the findings of the
aforementioned review articles are pertinent. The fact that
the 3D visualization technologies are continuously evolving
will probably enlarge their ability to accurately represent
anatomical structures, reinforce anatomy knowledge and be
beneficial for plastic surgery practice.
Funding
None.
Ethical approval
Not applicable.
Declaration of Competing Interest
None
References
1. Lo S, Abaker ASS, Quondamatteo F, et al. Use of a virtual 3D
anterolateral thigh model in medical education: augmentation
and not replacement of traditional teaching. J Plast Reconstr
Aesthet Surg 2020;73(2):269–75.
2. Chu TSM, Fan KS. Improving evaluation methods and study pop-
ulation to assess the educational value of the virtual 3D antero-
lateral thigh model. J Plast Reconstr Aesthet Surg 2020 S1748-
6815(20)30200-X.
3. Yammine K, Violato C. A meta-analysis of the educational ef-
fectiveness of three-dimensional visualization technologies in
teaching anatomy. Anat Sci Educ 2015;8(6):525–38.
4. Triepels CPR, Smeets CFA, Notten KJB, et al. Does three-
dimensional anatomy improve student understanding. Clin Anat
2020;33(1):25–33 Epub 2019 May 31.
5. Sayadi LR, Naides A, Eng M, et al. The new frontier: a review of
augmented reality and virtual reality in plastic surgery. Aesthet
Surg J 2019 Aug 22;39(9):1007–16 Epub 2019 Feb 12.
Dimitrios Chytas
Department of Anatomy, School of Medicine, European
University of Cyprus, 6, Diogenous Str., 2404, Engomi,
Nicosia, Cyprus
Michael-Alexander Malahias
Complex Joint Reconstruction Center, Hospital for Special
Surgery, 535 E 70th St, NY 10021, United States
Maria-Kyriaki Kaseta
2nd Orthopedic Department, School of Medicine, National
and Kapodistrian University of Athens, 3-5, Agias Olgas
Str., Nea Ionia 14233, Greece
2097
Corresponding author at: 75, Theotokopoulou Str., 11144,
Athens, Greece
E-mail address: dimitrioschytas@gmail.com (D. Chytas)
© 2020 British Association of Plastic, Reconstructive and Aesthetic
Surgeons. Published by Elsevier Ltd. All rights reserved.
https://doi.org/10.1016/j.bjps.2020.08.085
DIEP flap reconstruction as
salvage option for Poland
syndrome breast hypoplasia
Dear Sir,
Poland syndrome is a congenital abnormality mostly as-
sociated with unilateral hypoplasia of the sternocostal head
of pectoralis major, rib cage and upper limb abnormalities.
It may include absent or hypoplastic breast can which have
a significant psychological impact in female patients who
often experience body image disorders. Mild cases can be
improved with lipo-modelling, but traditional reconstruc-
tion options include Latissimus dorsi (LD) flap reconstruc-
tion with or without implant or a Transverse Rectus Abdomi-
nis Muscle flap1 . The use of a custom-made rubber silicone
implants based on 3D Computer Aided Reconstruction is an-
other option. Nevertheless, complications associated with
implants such as infection, rotation, rupture, capsular con-
tracture and poor cosmetic outcomes make perforator flaps
a valid alternative2 . The Deep Inferior Epigastric Perforator
flap (DIEP) is the gold standard in breast cancer reconstruc-
tion and the literature seems to be restricted to single case
reports from different units as primary treatment for Poland
syndrome2–5 . Several other factors probably also contribute
towards this, such as the young age at which affected fe-
male patients tend to present. In early adulthood, tissue
excess in the lower abdomen is uncommon which makes
harvesting a decent flap with a low donor scar technically
challenging. Additionally, breast development is not com-
pleted at this stage and, as a result, any intervention will
likely need significant adjustments to account for contralat-
eral changes in size and ptosis over time which is difficult
with a DIEP flap. It is however an ideal option when breast
development is complete and where implants have failed.
We present our early experience in Whiston Hospital with
3 female patients who underwent salvage surgery with a
DIEP flap reconstruction between 2012 and 2019. All our pa-
tients were previously treated with implants but were un-
happy with tightness in the chest and unsatisfactory cos-
metic results. Two patients had capsular contractures and
one patient had a ruptured implant. None of them had any
other medical problems. CT angiography was performed as
a routine method of perforator mapping, but in this occa-
sion to confirm internal mammary vasculature as well. The
DIEPs were performed by the senior author of this study.
The first female patient was 48 years old and initially
presented at the age of 17 with right sided absence of ster-
nal head of pectoralis major and hypoplasia of the breast.
She was treated with a 200 ml silicone implant which un-
2098
Figure 1 Pre-operative presentation with implant rupture.
Figure 2 Final result after implant removal, expansion, DIEP
flap, mastopexy, nipple reconstruction, lipomodelling.
fortunately ruptured. She presented to our department and
initially had exchange of the implant for a tissue expander
later replaced by a right DIEP flap which had an unevent-
ful recovery. Subsequent left breast mastopexy was carried
out along with right nipple reconstruction with areola shar-
ing and underlying cartilage. Two further lipo-modelling ses-
sions completed the reconstruction and she was satisfied
with the results. (Figures 1 and 2)
The Second patient was 42 years old and had under-
gone right Poland syndrome breast reconstruction with a
Becker implant and a left sided symmetrising implant. She
Correspondence and Communications
presented to us with grade 4 capsular contracture on the
right side and had removal of the right implant, capsulec-
tomy and DIEP flap reconstruction with an uneventful re-
covery. One year later, the skin paddle of the flap was inset
along with liposuction and left sided removal of implant and
mastopexy. The final procedure was a revision of the posi-
tion of the NAC to achieve a satisfactory result.
The third patient was 43 years old and previously had
an implant reconstruction for a right sided Poland syndrome
and left mastopexy. She presented with a ruptured implant
and had an uncomplicated DIEP flap reconstruction followed
a year later by lipofilling and adjustment of the skin paddle.
She was happy with the result and got discharged from our
care.
Although implant reconstruction remains the most com-
monly used method for Poland patient breast reconstruc-
tion, we have shown that autologous reconstruction gives a
better permanent cosmetic result with no sequelae of cap-
sular contracture or implant rupture. Autologous free flap
replacement should be considered for failed implant recon-
struction. Pre-operative imaging is essential and further re-
finement of results can be achieved with lipofilling and con-
tralateral symmetrisation. There is a clear need for more
studies so DIEPs and other free flaps can be routinely offered
to patients with Poland syndrome, especially when breast
development is complete or implants have failed.
References
1. Papadopulos NA, Eder M, Stergioula S, et al. Women’s quality of
life and surgical long-term outcome after breast reconstruction
in Poland syndrome patients. J Womens Health (Larchmt) May
2011;20(5):749–56 Epub 2011 Apr 18. doi:10.1089/jwh.2010.
2211.
2. Gautam AK, Allen RJ Jr, LoTempio MM, et al. Congenital breast
deformity reconstruction using perforator flaps. Ann Plast Surg
Apr 2007;58(4):353–8.
3. Liao HT, Cheng MH, Ulusal BG, Wei FC. Deep inferior epigas-
tric perforator flap for successful simultaneous breast and chest
wall reconstruction in a Poland anomaly patient. Ann Plast Surg
Oct 2005;55(4):422–6.
4. Wong TC, Lim J, Lim TC. A case of ductal carcinoma in situ
of breast with Poland syndrome. Ann Acad Med Singapore May
2004;33(3):382–4.
5. Liu Y, Xu J, Wang J. Clinical experiences of breast reconstruc-
tion using deep inferior epigastric perforator flaps. Zhongguo
Xiu Fu Chong Jian Wai Ke Za Zhi May 2006;20(5):534–6 Chinese.
Nikolaos Lymperopoulos
Department of Plastic Surgery, The Royal Marsden
Hospital NHS Trust, London, United Kingdom
Sami Ramadan, Ommen Koshy
Mersey Regional Plastic Surgery and Burns Service,
Whiston Hospital, Liverpool, United Kingdom
E-mail address: nslymperopoulos@hotmail.com (N.
Lymperopoulos)
Crown Copyright © 2020 Published by Elsevier Ltd on behalf of
British Association of Plastic, Reconstructive and Aesthetic
Surgeons. All rights reserved.
https://doi.org/10.1016/j.bjps.2020.08.094
Correspondence and Communications 2099

Notably, Zeis wrote: “We think we have provided an ad-

equate description of the current status of plastic surgery,”
but then adds, with his typical modesty, Tagliacozzi‘s warn-
The origins of modern ing: “sed, ut neque in universa medicina, imo in omni ac-
tionum genere. Cuncta firma sunt, et aeterna, ita neque
plastic surgery hic, quod jam diximus, perpetuum est,” “But nothing lasts
for ever, as in all of medicine and everything else that we do
or say.”2 Zeis and Tagliacozzi were well aware that plastic
Dear Sir, surgery is not an exact, but a historical science, that has to
modify its conclusions over time as knowledge changes. Not
In a fascinating editorial, Dr Zhang and Dr. Hallock draw only that. It must admit this, if it wants to be honest.
attention to the Dunedin connections of four pioneers of
Plastic Surgery; Gillies, Pickerill, Mowlem and McIndoe.
Dunedin is without doubt a charming location, but to grace Authorship
it “The Birthplace of Modern Plastic Surgery” is somewhat
dubious. All authors have made substantial contributions to all of the
As a consequence of the large numbers of severe max- following: (1) the conception and design of the study, or
illofacial injuries inherent in trench warfare, the Allies and acquisition of data, or analysis and interpretation of data;
the Central Powers fighting in Europe found themselves with (2) drafting the article or revising it critically for important
a new and vast spectrum of facial mutilations. Hastily im- intellectual content; and (3) final approval of the version to
provised specialized units were set up to treat the severely be submitted.
injured and disfigured.
Non-British pioneers were: French; Hippolyte Morestin,
Charles Valadier, Albéric Pont, Raymond Passot, Pierre Declaration of Competing Interest
Sébileau, Charles Claoué, François Dubois, Léon Dufour-
mentel; Americans: John Staige Davis, Vilray Blair, Vazartad The author declares that he has no conflict of interest.
Kazanjian; Russian: Vladimir Filatov, Vera Gedroits; Ger-
man: Christian Bruhn, Jacques Joseph, Hugo Ganzer, Otto
Lanz, Erich Lexer, August Lindemann; Turkish, such as: Cafer Acknowledgment
Tayar Kankat Cemil Topuzlu, Cafer Tayyar Kankat, Dr Halit
Ziya Konuralp, and Belgians, such as Maurice Coelst, and None
Gino Pieri in Italy, were those who established what is now
recognized as plastic and reconstructive surgery.1-5
Clearly, that fact that they rarely published in English
Funding
excluded the work of these pioneers from Gillies and the
British Empire and impeded their contributions to early
None
modern plastic surgery.1-5 Gillies was often unnecessarily
self-taught, and only his surgical inventiveness, daring and
social skills allowed him to come, with his cousin McIndoe,
to symbolize the speciality in the English speaking world. He
Ethical approval
had no time for the Europeans like Coelst and Esser in spite
No ethical approval required
of their translations. Despite being on its executive council
he took little interest in the European Society for ‘Structive
Surgery (founded by Maurice Coelst).
This very incomplete list of surgeons were faced with the Informed consent
same surgical challenges; it is fascinating to consider the
parallel developments in each country. An article in 1972 by Not applicable
J. P. Lalardrie in the British Journal of Plastic Surgery re-
counts that Morestin published six hundred and thirty four
References
articles in French, which limited his reputation in England. 1. Zhang WY, Hallock GG. Gillies and Dunedin: The birthplace
Esser’s magisterial book on arterialized flaps was published of modern plastic surgery. J Plast Reconstr Aesthet Surg.
in English in 1928, yet ignored by Gilles and his coterie. 2020;73:1012–17.
Most of the other war surgeons published widely, alas, of- 2. Von Graefe KF. Rhinoplastik; oder die Kunst den Verlust der
ten in their own language. Ludwig Wittgenstein, who fought Nase organisch zu ersetzen. in ihren früheren Verhältnis-
for the Austrio-Hungarian army and later became a famous sen erforscht und durch neue Verfahrungsweisen zur höheren
Volkommenheit gefördert. Berlin: Der Realschulbuchhandlung;
philosopher in the United Kingdom, wrote in his “Tractatus
1818.
logico-philosophicus” during World War One: “The limits of
3. Zeis E. Handbuch der plastischen Chirurgie. Berlin: G Reomer;
my language are the limits of my world.” Hopefully the ad- 1838.
vent of the international scientific exchange, the internet 4. Dieffenbach JF. Die operative Chirurgie. Leipzig: FA Brockhaus;
and easy translation will eventually no longer prove a bar- 1845.
rier to the general advancement of knowledge.
2100
5. Esser JFS. Die Rotation der Wange und allgemeine Bemerkun-
gen bei chirurgischer Gesichtsplastik. Leipzig: Vogel; 1918.
Sammy Al-Benna, Andrew Bruce-Chwatt
Division of Plastic and Reconstructive Surgery, Faculty of
Medicine and Health Sciences, Stellenbosch University and
Tygerberg Academic Hospital, Francie van Zijl Drive, PO
Box 241, Cape Town, Tygerberg 8000, South Africa
Andreas Gohritz
Department of Plastic, Reconstructive, Aesthetic and
Hand Surgery, University Hospital Basel, Basel,
Switzerland
E-mail address: albenna@sun.ac.za (S. Al-Benna)
© 2020 British Association of Plastic, Reconstructive and Aesthetic
Surgeons. Published by Elsevier Ltd. All rights reserved.
https://doi.org/10.1016/j.bjps.2020.08.095
The value of preoperative
computed tomography
angiography (CT-A) in
patients undergoing delayed
latissimus dorsi flap breast
reconstruction after axillary
lymph node dissection or
irradiation and suspicion of
pedicle injuryR
Dear Sir,
The latissimus dorsi (LD) flap first described by Tansini in
1906 has proven to be a versatile resource in breast recon-
struction remaining as one of the most popular reconstruc-
tive options. This flap is unmatched in reliability and its dis-
section is usually straightforward. Notwithstanding, when
the axilla is severely scarred due to a previous aggressive
lymph node dissection or irradiation, identification and dis-
section of the thoracodorsal pedicle may be laborious and
tedious carrying a risk of injury. On the other hand, as the
neurovascular flap pedicle is particularly vulnerable to in-
jury during axillary lymph node dissection, its cauterization
or ligation is not an uncommon complication. In this regard,
Santanelli et al. reported their experience on the acciden-
tal injury of the thoracodorsal pedicle during axillary dis-
section and proposed a classification and a reconstructive
algorithm.1
R This work was a podium presentation at Plastic Surgery The
Meeting, American Society of Plastic Surgeons (ASPS), Chicago, IL,
USA in September 28-October 1, 2018.
Correspondence and Communications
Although CT-A is a established practice study in the
preoperative planning of abdominal perforator flaps to
select optimal perforators and identify iatrogenic or con-
genital anatomical variations2 , 3 , its indication in delayed
cases of breast reconstruction with LD flap has received no
attention. Situations such as inconclusive physical examina-
tion, previous axillary radiotherapy or aggressive dissection
without a detailed record of past surgeries might justify its
indication.
Therefore, we aimed to elucidate the role of pre-
operative CT-A in patients undergoing delayed LD flap
breast reconstruction after aggressive axillary lymph dis-
section and/or irradiation assessing its indications and
benefits on surgical time, operative room fees and
outcomes.
Between January 2010 and January 2018 all patients un-
dergoing delayed LD flap breast reconstruction with a pre-
operative CT-A were included in the present study. Elec-
tronic clinical records were retrospectively reviewed to an-
alyze patients age, body mass index (BMI), referral center,
history of radiotherapy, and indications for preoperative CT-
A. The recorded operative time of every procedure was also
evaluated and compared to same number of consecutive pa-
tients undergoing LD flap breast reconstruction with similar
BMI in whom preoperative CT-A was not indicated (control
group). In addition to the analysis of their clinical records
the cost of preoperative CT-A and operating room fees
(per-minute) were compared between both cohorts. The
groups were also statistically compared using a parametric
test for independent samples (Student’s t-test), setting the
level of statistical significance at 0.05. An additional com-
parison considering the value associated with each group
was made, but this time considering the total surgical
costs, which depends on the surgical time and CT-A costs.
Statistical analysis was performed with IBM SPSS statistic
20.0 software.
A total of 26 patients were included in the present
study. Preoperative CT-A was indicated in 13 patients (study
group). All of them had history of axillary node clearance or
axillary radiotherapy. Information regarding the description
of the first procedure was not available or incomplete and
physical examination was not conclusive in eleven patients
who were referred from another distant center and in two
patients previously operated at our hospital. Patients demo-
graphics are summarized in Table 1.
CT-A findings showed patency of the thoracodorsal pedi-
cle in all patients in the study group (Figure 1). Although it
was reduced in its internal diameter in 3 cases (less than
1,5 mm), the partial occlusion was not considered to be se-
vere enough to preclude the procedure. The analysis of the
recorded operative time for the study group compared to 13
consecutive patients undergoing the same procedure with-
out preoperative vascular imaging (control group) showed a
mean saved time of 32 min. Regarding the cost analysis, at
our institution, the value of the CT-A is U$D 250, while the
operating room fee per hour is U$D 1380 (U$D 23 per min).
In this fashion, CT-A indication allowed an average saving
of U$D 486 per procedure. The statistical comparison be-
tween both groups using a parametric test for independent
samples showed significant differences in surgical time and
costs.
Correspondence and Communications 2101

Table 1 Patients demographics and cost analysis. This table shows the comparison between the two groups. The OR cost
at our institution is U$D 23/min while the cost of a thoracic CT-A is U$D 250. This makes a total surgical cost saving of U$D
486. The statistical comparison between both groups using a parametric test for independent samples showed significant
differences in surgical time and total surgical costs.
Parameter Study Group (CT-A) Control Group
Patients 13 13
Age: Mean and (range) 45 (36–53) y.o. 46 (40–55) y.o.
Mean BMI 20.6 kg/m2 21.3 kg/m2
Axillary lymph node dissection (ALND) 13 13
Axillary radiotherapy associated to ALND 3 –
Surgical time: Mean ± SD and range 172 ± 17.7 (146–199) min 204 ± 13.9 (175–226) min
Average surgical time difference 32 min less
Average OR cost ± SD U$D 3956 ± 408 U$D 4692 ± 319
CT-A cost U$D 250
Average total cost difference U$D - 486 U$D + 486
(Student’s t-test: p<0.05). Considering the level of statistical significance set and sample size, the study was able to detect
monetary differences over U$D 250 between groups obtaining a statistical power of 80%.

Figure 1 This CT-A image shows the patency of the thoracodorsal pedicle in a 48-year-old patient in whom her right axilla was
previously dissected during a mastectomy and her physical examination was inconclusive. The axillary artery and its branches
are indicated with arrows: a) axillary artery; b) thoracoacromial artery; b) lateral thoracic artery; d) subscapular artery and e)
thoracodorsal artery.

There are only two previous studies in the medical lit-
erature reporting the preoperative use of vascular imag-
ing to visualize the pedicle integrity. Pauchot et al. pro-
posed a systematic preoperative Doppler ultrasound imag-
ing of the thoracodorsal pedicle to detect altered flow.4
However, ultrasound is known to be an operator-dependent
imaging modality. Angiography was also previously proposed
as a more objective, although more invasive, way to ex-
plore the pedicle patency.5 Nowadays, CT-A has supplanted
invasive angiography providing high-quality vascular imag-
ing and valuable information on the patency of the ser-
ratus anterior branch and lateral thoracic artery. In pa-
2102
tients with severely scarred or irradiated axilla, preoper-
ative CT-A provides an additional benefit by avoiding the
axillary exploration and risk of injury. In our series, axil-
lary exploration avoidance decreased surgical times result-
ing in a more expedite and straightforward procedure. Cost
analysis of our data shows that preoperative CT-A costs in
these highly selected patients is compensated by the cut-
back in overall surgical costs while avoiding the risk of
pedicle injury. Notwithstanding, further prospective mul-
ticentric studies to confirm these preliminary findings are
needed.
Ethics
This study was performed in accordance with the ethical
standards as laid down in the 1964 Declaration of Helsinki
and its later amendments or comparable ethical standards.
For this kind of retrospective study formal consent form a
local ethical committee is not required.
Funding
This study did not receive any specific grant from funding
agencies in the public, commercial and not-for-profit sec-
tors.
Declaration of Competing Interest
The authors have no financial interest to declare in relation-
ship to the content of this presentation
Correspondence and Communications
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Horacio F. Mayer, Ignacio Piedra Buena, Maria
Laura Petersen
Plastic Surgery Department, Hospital Italiano de Buenos
Aires, University of Buenos Aires School of Medicine,
Peron 4190, 1st. floor (1181), Buenos Aires, Argentina
E-mail address: horacio.mayer@hospitalitaliano.org.ar
(H.F. Mayer)
© 2020 British Association of Plastic, Reconstructive and Aesthetic
Surgeons. Published by Elsevier Ltd. All rights reserved.
https://doi.org/10.1016/j.bjps.2020.08.096